Description: A licensee must do all of the following: (b) operate the community care facility in a manner that will promote (i) the health, safety and dignity of persons in care,

Corrective Actions Required: Ensure that the community care facility is operated in a manner that will promote the health, safety and dignity of persons in care. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On January 24, 2025, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: a revision of care sheets for more specific information was completed on January 2, 8, and 20, 2025, a review of "Comfort Rounds" policy and toileting documentation was completed with staff, toileting times were to be added to Point of Care (POC) documentation on January 20, 2025, and a review of the documentation report would be reviewed and submitted to Licensing on February 24, 2025.The corrective action plan was reviewed and accepted by Licensing. Licensing to review and monitor the corrective action plan.

Corrective Actions Taken By Licensee:

Actions Required By Licensing: Follow Up Inspection to be conducted.

To Be Corrected By: February 24, 2025

Observations: Regarding intake dated December 2, 2024. Through the investigation process, Licensing determined that the licensee did not operate the community care facility in a manner that promoted the health, safety and dignity of persons in care. Specifically related to ongoing documentation related to toileting.